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This is a case study of a trans man (born female) with many serious mental health problems, including an eating disorder. He was a survivor of childhood sexual abuse and the trauma seems to have been at the root of his problems.

This case study does not make any connections between his eating disorder and his gender dypshoria. Given the abuse and the multiple comorbidities, it is unlikely that the gender dysphoria caused the eating disorders.

The authors suggest that both the eating disorder and the gender dysphoria were caused by the early trauma.

“the underlying foundation of these multiple diagnoses is the presence of early developmental trauma to the emotion regulation system — which manifests as physical and emotional pain with impulsive and maladaptive attempts to engage in behaviors to meet personal needs, including safety. Zanarini and colleagues performed a study examining Axis I comorbidity in patients with BPD [borderline personality disorder] and identified high rates of comorbid PTSD. They also observed that meeting criteria for multiple Axis I disorders predicted meeting criteria for BPD.”

Medical transition came later and was not part of the recovery from the eating disorder. However, at the time the patient entered therapy, he had already taken a male name and was dressing and living as a male.

This case study has some similarities to the case of a teenage girl* who developed gender dysphoria while being treated for an eating disorder. The teenage girl was also a survivor of childhood sexual abuse with multiple mental health problems: anxiety, depression, an eating disorder, excessive exercise, and OCD-type rituals related to germs (spraying her body with Lysol and excessive hand-washing). In addition, she had a past history of PTSD, OCD, self-harm, and suicidal thoughts.

These two cases suggest that in some cases, gender dysphoria is not the main cause of an eating disorder. Rather, trauma causes multiple mental health issues.

There are two more case studies of transgender people with eating disorders who were survivors of child abuse. They suggest different possible conclusions, however.

A trans woman whose eating disorder began when she started to live as a woman. Her goal was to have a more feminine shape. Transition and hormones did not cure the eating disorder, however. She had been physically and sexually abused as a child.

A trans woman whose identical twin also had an eating disorder. Both twins were feminine in behavior from a young age and both were sexually attracted to men. Both survived an abusive father who threatened them with assault and death. However, one was a trans woman and one was a gay man.

In the first case, the eating disorder seems to be closely connected to the gender dysphoria since it started when she began to live as a woman. She clearly describes wanting to look more female. The abuse may have affected her, but gender dysphoria was also a factor.

In the second case, the eating disorder seems to have been caused by a combination of genes and environment, since both twins had anorexia but only one had gender dysphoria.

We’re left with the possibility that the answer is different in different cases. Sometimes severe childhood trauma may cause multiple mental health problems that include an eating disorder. Sometimes a combination of gender dysphoria and early childhood trauma may contribute to an eating disorder. And sometimes the same genes and environment will produce two people with similar eating disorders but different gender identities.

Of course, these are only four case studies. We can’t draw conclusions from them about all transgender people with eating disorders. Most of the case histories I have found don’t mention child abuse. Many of them suggest connections between gender dysphoria and eating disorders.

What we can see from these cases, however, is that for some transgender people with eating disorders, gender dysphoria is not the main or only cause of their eating disorder. Therapists should keep this in mind when treating transgender patients for eating disorders.

The article provides an interesting discussion of diagnosing and treating a patient. The full text is available online without cost, but here are a few details of the case:

The trauma the trans man survived involved “repeated episodes of sexual violence perpetrated from age 4 to 9 years old by a childhood friend’s father in the neighborhood.”

…

“The patient believed he had suffered multiple head injuries related to physical violence and asphyxiation in the context of sexual trauma, but was unclear if he had lost consciousness because of head injury or because of psychological dissociation during these events.”

…

He had “a history of heavy chemical use, starting with first use of alcohol at age 7, which continued through age 23. He also used diet pills starting at age 14, followed by heavy use of cannabis at age 15, and cocaine and other narcotics, including pills and heroin, at age 18 years.”

…

The patient had severe pelvic floor dysfunction which caused him a great deal of pain. It took him a while to get this diagnosed correctly.

…

“The patient was born and raised as a female, but in retrospect realized he did not fully identify with either the male or female gender. In the previous 2 years, he had decided to openly adopt a male gender, name, and manner of dress. He had the intention of pursuing hormone therapy and, eventually, chest reconstruction.”

…

Treatment and afterwards:

“Suicidal thoughts and behaviors were identified as the highest-priority target; after 6 months, these thoughts and behaviors had resolved. The patient was engaged in therapy and did not require significant emphasis on therapy interfering behaviors; therefore, quality-of-life interfering behaviors could be targeted, including purging behaviors, urges to use substances, self-injury, self-care, and interpersonally effective behaviors with friends, family, and other medical professionals. He graduated phase 1 of DBT therapy and proceeded to phase 2 to continue working on healthy emotional experiencing and management of trauma sequelae.

The patient graduated college with a high grade point average and went on to pursue master’s level education. He underwent sex hormone treatment and chest reconstruction.

He developed additional medical comorbidities, including insulin resistance and adrenal insufficiency. These medical conditions necessitated moving back in with his parents, resulting in significant familial conflict. The patient’s therapist made a referral for family therapy through our department, which was coordinated among treatment providers. The patient is enthusiastic about the progress made in treatment and states he often wonders if he would be still be alive without the intervention he received. Over the course of 3 years, his medications were all tapered to discontinuation, with the exception of prazocin 10 mg at bedtime for nightmares, ramelteon 8 mg for sleep, and clonazepam 1 mg three times a day, which was continued to assist with pelvic musculature functioning.”

This is a qualitative study of eating disorders and gender dysphoria. Its strength is that the authors asked transgender people themselves what they thought. Its weakness is that we can’t draw many conclusions from it, although we can use it to find questions for future research.

Limits of the Study

We can’t use it to estimate the prevalence of eating disorders among trans people. The participants were recruited for a study of body image and eating behaviors. Transgender people with eating disorders may be more likely to volunteer for such a study.

We can’t use it to collect statistics on trans people with eating disorders because the data is not uniform. Participants were asked open-ended questions, so we can’t be sure what it means when they give different answers. For example, one person talked about wanting to control his body. Did other participants agree with him and not think to mention it or did they just not care about controlling their bodies?

We can’t look at how individual eating disorders and gender dysphoria developed over time because we don’t have case histories of the participants.

The participants in the study were not formally diagnosed with eating disorders; the data on their eating is self-reported, although convincing. It is not clear from the study how many of the participants currently had symptoms of disordered eating.

On the other hand, we do have some data we can use from this study.

Data from the Study

The authors found 14 people with gender dysphoria who reported current or previous disordered eating and/or excessive exercise.*

About half of the transgender people with an eating disorder talked about gender dysphoria causing their eating disorder and about half did not.**

Other explanations given for the eating disorder included self-control, feeling like an outsider, struggle for autonomy, feeling that one did not deserve to eat, psychological stress and strain, and a belief that being thin would make sexual situations easier.

Explanations related to gender could be classified as efforts to suppress gender or efforts to accentuate gender.

A few participants talked about the relationship between disordered eating and transition. Some saw hormones as positive and some saw them as negative:

Two trans men (born female) said that hormone therapy had helped them to stop caring about their weight.

Two trans women (born male) said that hormone therapy had made them gain weight. (One of the women who said this was waiting for diagnosis and hormone treatment; presumably she was self-medicating.)

One woman who was considering gender reassignment said that breast reduction surgery had helped her stop caring about her weight.***

There was no clear relationship between medical transition and current scores on subscales of the Eating Disorder Inventory-3.**** The three people with the highest total scores included:

Two trans women who had had genital surgery and were on estrogen – the surgery means that their bodies were no longer producing much testosterone; and

One trans men who was taking testosterone and waiting for a mastectomy.

You can read further details of the study below the footnotes.

Future Research

The data we can get from this study isn’t much, but it does point to some important questions for future research. Many of these are questions raised by case studies as well.

What do transgender people see as the main cause of their disordered eating? Do they see it as being about issues like control, autonomy, and stress or do they see it as being related to gender dysphoria? Or both?

Is affirming the desired gender or suppressing biological sex a more important factor in disordered eating? Do trans men and trans women give different answers to this question?

Are there differences between the group of people who see their eating disorder as being related to gender issues and those who do not? Do they have different patterns in terms of when their symptoms of disordered eating developed, what their symptoms looked like, or what happened when they transitioned?

Do people’s perceptions of what causes their disordered eating match reality? Do they have relatives with eating disorders, for example? Were there other factors in their life that might have contributed to the eating disorder? When did the eating disorder develop?

How does the relationship between the eating disorder and gender dysphoria affect recovery from the eating disorder?

When did the disordered eating begin in relation to the gender dysphoria? How did the two conditions develop over time?

Does transition increase or decrease symptoms of disordered eating? Does it have no effect?

Are the effects of transition on eating disorders different for trans men and trans women? In this study, two trans men with eating disorders felt hormone therapy helped their recovery, while two trans women said it made them gain weight.

Trans women and trans men are not getting the same treatment for gender dysphoria; how does that affect eating disorders? In this study, trans men had mastectomies while trans women had genital surgery. Mastectomies might be more important in issues related to body shape. In addition, hormone therapy would have involved completely different medications for trans men and trans women.

Do the hormones themselves play a role in eating disorders, either reducing or increasing symptoms?

Comparison to Case Studies

Prevalence of eating disorders in trans men versus trans women

In this study, slightly over half of the participants were trans men. Trans women were not more likely to have eating disorders than trans men. In contrast, the case studies are overwhelmingly of trans women with eating disorders. What is the real prevalence of eating disorders among transgender people? Is there a difference in the rates among trans men and trans women or not?

It might be that selection bias means that case studies of trans women with eating disorders are written up more frequently. Eating disorders are relatively rare among biological males and potential authors of case studies might notice them more. Conversely, it might be that trans men were more willing to volunteer for the study than trans women or that a group of trans men encouraged each other to participate.

The link between eating disorders and gender dysphoria

Some case studies suggest that factors other than gender dysphoria are central in the development of disordered eating. We have the case of the identical twins who both had anorexia, although only one was transgender. Similarly, the trans man with an eating disorder in this case study had two cousins with eating disorders and this boy’s mother had had anorexia. Then we have the case of the teenage survivor of sexual abuse with PTSD, generalized anxiety disorder, OCD, an eating disorder, and a history of self-harm. The teenager developed gender dysphoria while being treated for her eating disorder; it may be that the trauma was the most important factor in all of her problems.

On the other hand, we have five cases of trans women whose eating disorder began when they decided to live as women, reported in this case study, this one, this one, and this one. In addition, in this case study, one trans woman’s eating disorder seems to have begun at the same time as depression related to her gender.

We also have a couple of case studies where trans men say that their disordered eating was a desire to get rid of feminine features; in this case his curves, breasts, hips, and feminine face and in this case his period and feminine shape. However, in the first case, the trans man also had two cousins with eating disorders.

There is also this somewhat unusual case of an underweight boy with poor eating habits who developed severe anorexia after a doctor suggested that he take testosterone to induce puberty. Again, in this case, his mother had also had anorexia.

Intriguingly in these two cases, gender identity seemed to affect the patient’s symptoms, but not the underlying dissatisfaction with their bodies. In the first case, the patient had a fluid gender identity; when he lived as a man he tried to gain weight and muscle, when he lived as a woman he tried to lose weight. His habits were always pathological and he always hated his body. In the second case, the patient initially identified as a woman. After coming out as gay to supportive friends, he identified as a gay man; as a woman he dieted and as a man he tried to gain muscles.

Of course, since they are case studies, there could be some selection bias. People might be more likely to report cases where gender identity seemed to have affected the eating disorder – or they might be more likely to report cases that are unusual like identical twins and fluid gender identity.

This is where this study is helpful; we see that a number of transgender patients did not bring up gender issues when asked what they thought caused their eating disorders. We also see that some patients thought gender issues were important causes. And now we need another study to find out what that means.

The effect of transition on gender dysphoria

This study found one person considering transition who said that breast reduction surgery had helped her with her disordered eating,

In contrast, there are three individual case studies where sex reassignment surgery contributed to an eating disorder. This trans man began binging and purging for the first time after having his breasts, uterus, and ovaries removed. One of the trans women in this study had an eating disorder in adolescence; her symptoms returned after sex reassignment surgery 20 years later. Finally, this adolescent trans man recovered from an eating disorder and transitioned; after his mastectomy, he began to relapse and ten months later he returned to the clinic for eating disorders.

In the qualitative study two trans men said that hormone therapy had helped them with their eating disorders, while two trans women said hormones had made them gain weight.

On the other hand, two trans women and a trans man who were taking hormones had relatively high scores on three subscales of the Eating Disorder Inventory-3. The two trans women had already had genital surgery (which would have included removing their gonads) while the trans man was waiting for a mastectomy.

Looking at the case studies, there were two trans women with eating disorders who were already on hormones (here and here), although one of them does not seem to have been interested in recovering from her disordered eating. There was one trans woman who believed that transition had cured her, but she was severely underweight, even more so than she had been before transition. In addition, the patients listed above who had problems with their eating after sex reassignment surgery were also on hormones, although it could still be that hormone therapy initially helped them.

On the other hand, there was one trans man whose eating disorder was cured by taking testosterone. In addition, taking puberty blockers helped this adolescent trans woman restore her weight, although, of course, puberty blockers are not the same as hormone therapy for trans women or trans men.

In many of the case studies, patients recovered from disordered eating before they were referred to a gender clinic.

It seems clear that we can not rely on transition to cure an eating disorder and at times it may exacerbate it. Therapy for eating disorders should be aimed at the eating disorder and patients with gender dyshporia and eating disorders should have follow-up care for the eating disorder after they transition.

You can read further details of the qualitative study below the footnotes.

*I count 16 people with an eating disturbance or excessive exercise, according to their Table 2. I’m not sure if this is a typo or if two people reported symptoms that were not considered severe enough to be an eating disorder.

**It is difficult to tell from the study how many people identified gender dysphoria as a cause of their eating disorder. The study talks about 5 people who were suppressing their gender and 3 people who were accentuating their gender, but the two groups overlap. They quote one person twice for both suppressing and expressing their gender. There is no list of which people talked about which possible causes for their gender dysphoria, so there could be more overlap.

Based on the quotes they include, at least seven and possibly eight people mentioned something to do with gender as a possible cause of their eating disorder. This means at least six or seven did not.

It is also possible that some of the people who mentioned gender dysphoria as a possible cause of their eating disorder also mentioned other possible causes. Or that some people did not answer the question.

*** There was also one trans woman (“Julie”) who felt that genital surgery had made her less self-conscious about her body and her weight. However, she had never had any symptoms of an eating disorder or excessive exercise. Her case does not answer the question of how eating disorders may be related to gender dysphoria, especially since there is a group of people with eating disorders and gender dysphoria who did not say that gender issues affected their eating.

****The participants were tested on the Drive for Thinness, Bulimia, and Body Dissatisfaction sub-scales of the Eating Disorder Inventory-3.

More Details on the Study:

Eating Disorders and Gender Dysphoria

The authors found 14 people with gender dysphoria who reported current or previous disordered eating and/or excessive exercise. Looking at their Table 2, I count 16 people with disordered eating and/or excessive exercise, but perhaps there were two cases where the symptoms were not severe enough to be considered disordered.

Of these 14 people, seven or eight mentioned gender as a cause of their eating disorder or excessive exercise (see footnote above as to why the number is unclear). This included 6 or 7 trans men and 2 trans women.

Six or seven people did not mention gender as a cause of their eating disorder or excessive exercise.

Other explanations given included self-control, feeling like an outsider, struggle for autonomy, feeling that one did not deserve to eat, psychological stress and strain, and a belief that being thin would make sexual situations easier.

“I have always wanted to feel that I can control my body.”

“I have felt like I was an outsider since I was little. I have felt inadequate, like I don’t belong to the group, and because of that any criticism about what was most essential to me, my body and how desirable I am, was a really serious thing to me.”

“At that age [eating] was really the only thing I could have an influence on.”

Explanations related to gender fell into three categories –

suppressing gender (“The background of that crazy weight loss was that my curves would disappear”),

accentuating gender (“It is easier to make a man’s body look feminine if you’re a bit thinner”), and

enhanced masculinity (“[After losing a lot of weight] I could buy pants at the men’s department, and they fit in a certain way, the right way, as I see it.”)

Four trans men mentioned suppressing gender, one trans man mentioned accentuating gender, and one trans man mentioned enhancing masculinity. It is possible that there is some overlap between the categories.*

One trans woman mentioned accentuating gender and one trans woman mentioned both accentuating and suppressing gender as possible causes of disordered eating.*

Eating Disorders and Transition

The authors identified sixteen people who had already begun hormone therapy and/or had surgery. In addition, one trans woman seems to have been self-medicating and one trans man had already had breast reduction surgery. Of these 18 people:

Two trans men said that said that taking testosterone had helped them recover from their eating disorder; they stopped caring about weight gain.

Two trans women said that taking hormones caused weight gain and in one case, problems with blood sugar. It is not clear exactly which medications they were talking about – estrogen and blockers or just estrogen. One of the trans women who said this was waiting to begin hormone treatment, so presumably she was self-medicating.

One woman who was considering gender reassignment said that breast reduction surgery had helped her recover from her eating disorder. She no longer cared about weight gain after the surgery.

One trans woman said that after genital surgery she felt comfortable in her body and didn’t care about any fat. However, she had never had any symptoms of disordered eating or excessive exercise, so this may not be relevant to people with eating disorders.

Current Scores on Subscales of the Eating Disorder Inventory-3 (EDI-3)

The study does not separate data on current symptoms of disordered eating and excessive exercise from data on past symptoms. However, the study participants completed three subscales from the Eating Disorder Inventory-E (EDI-3): Drive for Thinness, Bulimia, and Body Dissatisfaction.

We can not use the scores on three subscales of the EDI-3 to diagnose an eating disorder, but they may give some indication of how the participants are doing now.

Of particular concern are “Sue,” “Martha,” and “Leo.” Sue and Martha are trans women who had had genital surgery and were on hormones. Leo is a trans man who was on hormones but was waiting for a mastectomy.

Sue scored 16 on the drive for thinness scale, 17 on the bulimia scale, and 21 on body dissatisfaction. Martha scored 9 on the drive for thinnness scale, 9 on the bulimia scale, and 22 on body dissatisfaction. Leo scored 14 on the drive for thinness scale, 11 on the bulimia scale, and 34 on body dissatisfaction. The three of them had the highest total scores compared to any of the other study participants.

This is a fascinating study of identical twins; one had gender dysphoria and one did not. Both twins developed anorexia.

Both twins were feminine in behavior from a young age and both were sexually attracted to men. Both had a difficult childhood with an abusive father.

Both twins were underweight at birth and needed intensive care. Both had developmental delays.

However, one twin considered himself to be a gay man while one identified as a straight woman.

In this case study, gender dysphoria did not cause the eating disorder.

This case highlights the importance of other factors in eating disorders, including genes, hormones, and trauma.

It raises the question; how important is gender identity as a cause of eating disorders?

This case is different from other case studies where gender dysphoria seems to be intimately linked to the eating disorder.

We can’t look at these two patients and conclude that gender dysphoria never contributes to eating disorders. However, this case is a good reminder to be cautious about drawing conclusions from other case studies. Perhaps there are just some people with eating disorders who also have gender dysphoria. Or perhaps there is some other factor which causes both eating disorders and gender dysphoria.

As always, we need more studies.

More about the Patients:

Eating Disorders

Twin A was diagnosed with AN-purging subtype and Twin B was diagnosed with AN-restricting subtype.

Twin B developed an eating disorder at an earlier age, but Twin A was more underweight and had a more disturbed perception of his body. Furthermore, Twin A was hospitalized for his eating disorder and Twin B was not.

Neither twin seems to have been able to maintain a healthy weight.

At age 16 Twin A“was admitted to a children’s hospital because of AN. Later, he was hospitalized in the psychiatric inpatient unit for adolescents. At first, his eating behavior was restrictive. Then he reported intermittent vomiting (AN binge-purge). His weight decreased to 46 kg/1.79 m (body mass index [BMI] ¼ 14.3 kg/m²). His ideal weight was 44 kg according to a BMI of 13.7 kg/m² , which shows his severe disturbance in body perception. During hospitalization, his behavior was sometimes aggressive. He was emotionally unstable, depressed, and was rarely able to engage in stable relationships. Despite strict dietary rules, he achieved a maximal weight of 55 kg (BMI ¼ 17.2 kg/m²). Soon after being discharged, his weight decreased again.”

Twin B’s eating disorder began at a younger age. “In puberty, he developed severe underweight. At the age of 13, he was 42 kg/1.58 m (BMI ¼ 16.8 kg/m² ). When he was referred to our outpatient unit at the age of 18½ years [for gender dysphoria], his weight was 48 kg and his height was 1.76 m (BMI ¼ 15.5 kg/m² ). He denied deliberate dieting, binging, or purging. Although he regarded himself as too slim, he did not manage to gain weight. Further medical checkups revealed no somatic cause for his underweight. An osteodensitometry yielded an osteopenia of the spine.”

Gender Identity

Twin A was a gender non-conforming gay male:

“In childhood, he preferred girls’ games and toys (Barbie dolls) and was very close to his twin brother. His sexual feelings were always for males. Although he started cross-dressing at the age of about 16 years, his gender identification was always male. He considered himself to be a homosexual.”

Twin B was a trans woman:

“As far as he could remember, he had felt he was a girl, preferring girls as playmates and had started cross-dressing at nursery school. In gymnastic lessons, he refused to change with the other boys because he was ashamed of his body. Eventually, he refused to attend sports lessons at all. When he was 9 years old, he started to grow his hair. His class mates seemed to accept him as a girl. When he started to work as a hairdresser, he tried to correspond to the male gender role and did not cross-dress. However, at his professional school and in his free time, he continued to cross-dress. His employer, who realized he was transsexual, permitted and encouraged him to cross-dress at work, which consequently allowed him to live as a young woman. Sexually, he was always attracted to men. However, in contrast to his brother, he never considered himself to be homosexual and viewed this attraction as ‘‘heterosexual.’’ Until this point, he had not engaged in sexual relationships either with men or with women.”

Twin B requested hormonal and surgical sex reassignment.

Childhood

The twins grew up together in a small Swiss city without any other siblings. Their childhood was not easy:

“[Their father] was very authoritarian. He could not accept the sexual orientation and the cross-dressing of his sons and threatened them with assault and even with death.

…In family conflicts, [their mother] took a position between her husband and her sons. At a family consultation, she appeared emotionally unstable.”

Birth

The birth was a difficult one. Both twins were underweight and spent time in intensive care.

“the mother had been admitted to a hospital with hypertension, edema, and proteinuria at 38 weeks of gestation. The vaginal delivery was induced because of maternal preeclampsia. Twin A weighed 2.17 kg at delivery and his Apgar score was 9/9/9. Because of perinatal acidosis and hypotonia, he was kept in the incubator for 3 days. He was diagnosed with a subependymal hemorrhage with ventricular invasion. Twin B’s birth weight at delivery was 1.95 kg and his Apgar score was 7/9/9. Both twins were admitted immediately to the neonatal intensive care unit.”

Developmental Delays

They both had developmental delays:

“In early childhood, Twin A showed a developmental delay in language and motor skills and had deficits in cognitive and verbal skills. He was socially isolated and his behavior was often aggressive.”

“…Twin B had delays in language and motor development during early childhood. He showed the typical symptoms of attention deficit and hyperactivity disorder. The parents refused further assessment and treatment.”

Other

Twin A was diagnosed with borderline personality disorder and subnormal verbal intelligence.

Twin B was diagnosed with gender dysphoria.

There is no obvious pattern to any of this. Twin A was larger at birth, but had more problems right after birth. Both had developmental delays, and Twin B may have had ADHD as well. Both were feminine in their behavior, but only Twin B developed gender dysphoria. Both were sexually attracted to men. Twin B developed an eating disorder earlier, but Twin A’s eating disorder seems more severe. Twin A has borderline personality disorder and Twin B does not.

Discussion

The authors offer two possible hypotheses about the twins’ gender identity.

Perhaps the twins are on a continuum of gender non-conformity where gender dysphoria is at the extreme end.

Alternatively, perhaps gender dysphoria* in childhood is inherited, but the later development of gender identity is determined by environmental factors and psychiatric comorbidity.

“In childhood, both Twin A and Twin B showed gender atypical behavior and stereotypical feminine traits and interests. In adolescence, their sexual orientation was revealed to be homosexual. Twin A developed effeminate homosexuality with male gender identity, whereas Twin B stabilized his cross-gender identity. Although Twins A and B are concordant for GID in childhood and sexual orientation on a categorical level, they are now discordant for TS. On a more dimensional level, one could argue that Twins A and B show an opposite sex-dimorphic behavior and that they arrived at different points of a continuum. The fact that GID in childhood is a predictor for later homosexuality and TS could support the dimensional view. It could be hypothesized that GID in childhood is mainly hereditary, whereas the development of the later phenotype of the gender identification is determined by environmental factors and psychiatric comorbidity, as any difference between MZ twins provides strong evidence for the role of environmental influences.”

The authors also discuss the relationship between gender and eating disorders. However, they don’t address the fact that the two twins had different gender identities, but both had eating disorders.

Perhaps both gay men and trans women are vulnerable to eating disorders for different reasons, but perhaps genes, hormones, and environment matter more than gender identity.

“Homosexual men seem to have an increased vulnerability to eating disturbance and body dissatisfaction (Williamson & Hartley, 1998), are more dissatisfied with their weight (French, Story, Remafedi, Resnick, & Blum, 1996), and are more concerned about their attractiveness (Siever, 1994). Male AN is associated with disturbed psychosexual and gender identity development, which supports the hypothesis that males with atypical gender role behavior have an increased risk of developing an ED (Fichter & Daser, 1987). Furthermore, feminine gender traits are discussed as a specific risk factor for ED in men and women (Meyer, Blissett, & Oldfield, 2001). Although the role of sexual orientation as a risk factor for ED is well documented, there is hardly any literature about GID and ED. For men with disturbance of gender identity in addition to the aforementioned factors concerning sexual orientation, underweight could be a way to suppress their libido and the expression of their secondary sexual characteristics and, at the same time, correspond to a female ideal of attractiveness (Hepp & Milos, 2002).”

We need more research!

“Further research in eating behavior and body dissatisfaction in patients with GID could provide more insight into the role of gender identity in the development of ED and lead to a better understanding of ED as well as GID.”

* In this case, gender non-conformity might be a more fitting phrase. Twin A does not seem to have ever wanted to be a girl.

This is a somewhat surprising case report of a trans man (born female) who developed anorexia nervosa after sex reassignment surgery.

The 24-year-old patient had surgery to remove his breasts, ovaries, and uterus. Afterwards he began binging and purging. He had not had problems with eating behaviors or weight loss before surgery.

This case is similar to the trans woman (born male) in this study who began to diet excessively after sex reassignment surgery. It is, however, different from this trans man who stopped dieting once he was on hormones and menstruation ceased.

The authors suggest that the eating disorder is an “expression of a gender identity process, or a conflict of an acceptance of one’s own sexuality.”

It is easy to understand why someone with gender dysphoria might dislike their body and develop problems eating, but in this case, the patient had already changed his body.

Why did the eating disorder develop after physical transition was complete?

Had he been focused on changing his body with hormones and surgery and then when he was done, he focused on his shape?

Was his eating disorder a sign of persistent body dissatisfaction no matter what he did?

The authors suggest that the patient’s underlying problems may have caused the eating disorder:

“In this case, there was clearly a linkage between a lack of sense in self-efficacy and a body dissatisfaction that continued after the sex change surgery. Discomfort with her/his own body appeared to be more deeply anchored than just being rooted in the wish to change the physical appearance.”

Alternatively, might the surgery have caused an abrupt shift in hormones that led to an eating disorder? More importantly, could adjusting his hormones help him recover from the eating disorder?

We think of testosterone and estrogen as sex hormones, but they are much more than that. Like all hormones, they are part of a complex system of chemicals that affect each other. Specifically, we know that “sex” hormones also play a role in appetite.

“The sex hormones estrogen, progesterone and androgens are involved in the complex regulation of appetite, eating and energy metabolism. In most species, including man, food intake and reproductive functions are closely linked. Thus, during the different hormonal phases of the menstrual cycle daily food intake varies and, moreover, remarkable physiological adaptations of appetite and body composition occur during pregnancy and lactation. In addition, regulation of eating behaviour and metabolic functions by sex hormones is of considerable general importance for women’s health, as indicated by the disturbances in this regulation associated with a number of clinical disorders.”

In this case study, the patient’s estrogen levels would have dropped significantly after his ovaries were removed. In addition, doctors normally reduce the dose of testosterone after surgery, although to a level typical for a man.

Women eat less during the phase of the menstrual cycle when estrogen levels are high, so it is possible that a drop in estrogen levels would be connected to eating more.

Furthermore, bulimia may be connected with polycystic ovary syndrome (PCOS), a syndrome which is characterized by elevated androgen levels.

Testosterone stimulates appetite and high circulating levels of this androgen in women have been associated with impaired impulse control, irritability and depression, i.e., common features of women with bulimia. Accordingly, it has been proposed that elevated levels of androgens may promote bulimic behaviour by influencing craving for food and/or impulse control. Hypothetically, bulimia may, in some cases, have a hormonal, rather than a psychiatric etiology, a suggestion supported by the observation that antiandrogenic treatment reduces bulimic behaviour. This may turn out to be a novel and valuable approach to treating women with BN, particularly those with hyperandrogenic symptoms.

The patient in this case study had symptoms that are typical of bulimia, binging and purging. Perhaps in his case the bulimia was related to the sudden drop in estrogen after surgery coupled with male levels of testosterone.

Most people do not develop eating disorders after sex reassignment surgery. There would have to be other factors involved, possibly genetic or psychological.

We have very little data on eating disorders and gender dysphoria, just a set of case studies.

However, we now have two cases of trans people developing an eating disorder after having surgeries that would have changed their hormones.

In one case, a trans woman began restricting her eating after surgery; in her case the surgery would have decreased her testosterone levels and thus, possibly decreased her appetite.

In this case, a trans man began binging and purging after surgery which would have decreased his estrogen levels and thus, possibly increased his appetite.

We need more research into this question. Do changes in hormones trigger eating disorders in some trans people? Most of all, can we use this to find a way to help trans people with eating disorders?

The patient also had problems with alcohol and drug abuse, self-mutilation, and suicide attempts, but these had begun at age 17. He was diagnosed with “gender identity disorder, alcohol dependence, anorexia nervosa (purging subtype), major depression (Axis I), and borderline personality disorder (Axis II).

The patient’s father had obsessive-compulsive disorder and one of his sisters had an affective disorder.

As a child, the patient felt like a boy, didn’t play with girls, tried to hide any feminine parts of his silhouette, and hated feminine features of his body.

Two more case histories of trans women (born male) with eating disorders, this time from the United Kingdom.

There are many more case studies of trans women (born male) with eating disorders than trans men (born female). This may mean that trans women are more likely to have eating disorders than trans men.

Alternatively, it might mean that therapists are more likely to write case studies about trans women with eating disorders.* It may be that therapists are more surprised to find patients who were born male with eating disorders because eating disorders are rare in males. It might also be that therapists are interested in trans women with eating disorders because these cases support the theory that femininity and female socialization contribute to eating disorders.

We need more research on the prevalence of eating disorders among people with gender dysphoria.

Back to the case reports. As with other cases, each one is a little different from all the others.

In the first case the patient had a long-standing eating disorder that was clearly linked to her gender dysphoria. She also had had a difficult childhood and was depressed. The patient had to be hospitalized twice for her eating disorder, but was eventually able to maintain a normal weight. She was referred to a gender identity clinic.

The second patient described anorexia as “providing an escape from emotional pain, confusion, and dissatisfaction with [her] life,” although she also wanted a more feminine physique. She eventually suggested that she could not resolve her eating disorder and depression until she dealt with her gender dysphoria. She was referred to a clinic and transitioned.

This is where it gets confusing. After surgery, she felt complete and normal and her mood stabilized. In terms of the eating disorder:

Although she remains underweight (weight 52.4 kg, BMI 16.2 kg/m²), she now feels more satisfied with her body shape. Her only current concern in terms of body image is that her breasts are too small.

The authors believe that she is doing well. However, a BMI under 16 is dangerously thin and her BMI is only 16.2. Furthermore, she weighed 20 pounds more when she started treatment for her eating disorder than she did after transition.

Her gender dysphoria has been resolved, but I am not sure about her eating disorder. A BMI below 17.5 may be a sign of anorexia. You cannot diagnose anorexia without more information, but her low weight is a red flag.

So, we have two more cases where an eating disorder was linked to gender dysphoria. In one case, the patient was treated for her eating disorder in the hospital and was eventually able to maintain a normal weight. In the other case, the patient decided she needed to deal with her gender dysphoria in order to cure her eating disorder; it is unclear if this approach worked.

There are three cases of trans women who transitioned and still had eating disorders, described in this study and this study. In one case, the trans woman had an eating disorder as a teenager and it returned years later after she had sex reassignment surgery.

In this study and this one, the young patients’ eating disorders were treated without transition. However, in this study the use of blockers helped a young trans woman recover from her eating disorder. Finally, this trans man’s eating disorder was cured by transition.

These are, of course, case studies so we can not draw broad conclusions from them. Case studies bring home the individual nature of each patient’s history.

More details about Patient 1:

The first patient had a long-standing eating disorder.

“His** symptoms included a desire to be thin, distorted body image, fear of fatness, self-induced vomiting, and laxative abuse. He attributed his desire for thinness to a wish to attain a more feminine physique. The onset of his eating disorder was associated with the development of depressive symptoms, which he attributed to the fact that he could not be a woman.”

Her eating disorder was very severe with marked dietary restriction, frequent vomiting, extreme laxative use, and exercising. Her BMI was 17.0 kg/m². She was involved in internet chat rooms related to eating disorders. She was depressed, she lacked energy, she couldn’t sleep, and she couldn’t concentrate.

Her eating disorder did not begin when she decided to live as a woman as it did for the patients in this study, this study, this study, and one of the patients in this study. However, it seems to have begun at the same time as depression related to her gender, so her eating disorder is closely linked to her gender dysphoria.

She had had a difficult childhood and could not remember much of it.

“…as a child he had felt isolated from his family and peers and was shown little affection by his mother. His mother had wanted a daughter and he felt that he might have received more affection as a girl. His father, who was described as stern and authoritarian, died when he was 15 years old.”

She had been bullied at school.

She “took the female role in play” as a child and had cross-dressed starting at age 6 or 7. “During adolescence and early adulthood, he attempted to prove his masculinity by drinking heavily and becoming involved in football-related violence. However, he never felt comfortable with a male identity. He subsequently developed strong religious beliefs, which conflicted with his wish to be female and resulted in powerful feelings of guilt. These beliefs also prevented him from contemplating gender reassignment surgery. He has had one short-term heterosexual relationship. His sexual fantasies are directed towards men but take the form of being treated like a woman rather than being clearly homosexual.”

The patient requested hospitalization for her eating disorder. She gained weight well, but she began to self-harm and think about suicide.

Her treatment involved therapy that seemed to help her.

“Within individual psychotherapy, he explored issues of masculinity and maternal neglect. He appeared to experience the hospital as providing the nurturing that he had lacked as a child. It became clear that his motivation for weight loss reflected a need for a sense of internal control and clarity in the face of a confused identity. In addition, he felt that he was attempting to starve the masculine part of himself.”

She reached a normal weight, but when she left the hospital, she relapsed and had to be readmitted.

However, at the time of the case report, she was maintaining a normal weight and had been referred to a gender clinic.

The treatment of her eating disorder included therapy around her childhood trauma and her gender issues. Transition was not part of the treatment for her eating disorder, however, it may be that the referral helped her to maintain her normal weight. The timing of the events is unclear from the article.

More details on Patient 2:

The second patient had been restricting her eating for the past 13 years, since she was 28. She had “a marked preoccupation with shape, including a desire to have a more feminine physique.” Her BMI was 18.8 kg/m², which would be just within the range for normal weight.

She had had a happy and caring home life and was close to her parents who she still lived with.

However, “from the time he started school, Patient 2 felt that he did not fit into the male gender. At school, he was bullied for being passive and sensitive. He had no friends and felt he had more in common with girls than boys. He had difficulty with some subjects at school. As an adult, he was diagnosed as dyslexic but this was not recognized in childhood. He completed a qualification in electronic engineering and worked for many years as an engineer. He denied sexual feelings of any sort and has never had a sexual relationship.”

She had been referred for psychological problems seven years ago and had raised the issue of her gender dysphoria then. She was given anti-depressants, but felt that her gender issues had been ignored.

Her eating disorder did not begin when she decided to live as a woman as it did in some other cases. However, she may have been trying to look more feminine.

She began outpatient counseling for her eating disorder.

“He described AN as providing anorexia as a an escape from emotional pain, confusion, and dissatisfaction with his life. He eventually expressed his belief that his AN and depression would not resolve until his concerns regarding gender identity were addressed. He was subsequently referred to a gender identity clinic.”

As I said above, this is where it gets confusing. She transitioned and was happier, but she was even more underweight than when she began treatment. Has she truly recovered from her eating disorder or not?

“After living as a female for 2 years, he underwent gender reassignment surgery. Since the surgery, she describes herself as feeling complete and normal. Her self-confidence has increased and she feels more at ease with herself. Her mood has stabilized. Although she remains underweight (weight 52.4 kg, BMI 16.2 kg/m² ), she now feels more satisfied with her body shape. Her only current concern in terms of body image is that her breasts are too small. She has completed professional training in counseling and adult education in the female role. Although she feels the need to be in a relationship, she has no desire for a sexual relationship.”

Comparing the Two Cases

The authors conclude by comparing the two patients. In both cases the desire for thinness was associated with wanting to look feminine. In addition both patients had educational differences.

However, in the first case, “significant emotional deprivation” as a child may have made her problems more severe and harder to treat.

“This difference seems to have been reflected in the clinical presentation and response to treatment. Patient 2 was able to make good use of outpatient psychotherapy and subsequently showed a good response to gender reassignment surgery. Patient 1, by contrast, had a complicated clinical course and required inpatient treatment on two occasions. In his case, GID was associated with disturbed early relationships and a global disturbance of identity which was not restricted to gender.

We suggest that GID in Patient 1 may have had its origins in early psychological development. We speculate that, in his case, the issue of gender identify may have served to express more complex issues of personal identity. GID, like AN, may have provided the patient with a sense of structure in a chaotic internal world. Patient 2, however, may be thought of as having a more ‘‘biologic’’ form of GID, which accounts for the successful response to gender reassignment surgery. Furthermore, the lack of major personality disturbance in her case enabled her to be treated as an outpatient.”

The author conclude by suggesting that clinicians look at issues of gender identity whenever they have male patients with eating disorders.

In this case study, the eating disorder was closely connected to gender dysphoria, although transition did not cure it. The patient’s life history may also have contributed to her eating disorder.

The patient was a 25 year old trans woman (born male) in New Zealand. Her eating disorder began when she started living as a woman at age 15. The goal of her restricted eating and purging was to have a more feminine shape and attract men. When she tried to live as a man for six months, her symptoms decreased.

The patient was a survivor of physical and sexual child abuse. She ran away from home and school before she was 15* and at 16 she was hospitalized for self-harm. She had had short and often violent relationships with men. She was currently unemployed, but had worked in the hospitality industry and as a self-employed escort.

Transition did not cure her eating disorder. She was taking hormones and living as a woman when she came to the clinic for eating disorders. According to the clinicians, she had a “convincing female appearance.”

Treatment is hard to evaluate in this case, however, because the patient did not want to stop her restricted eating and vomiting. Instead, she asked about more efficient ways to change her shape.

It is important to remember that this is just a case study of one individual; the relationship between eating disorders and gender dysphoria is complicated. The main conclusion I have reached in looking at case studies is that each person’s story is different.

However, like the patients in this study and this one, her restricted eating and purging began when she decided to live as a woman. For some trans women, eating disorders are clearly linked to gender dysphoria.

The patient also had a history of trauma like one of the patients in this case study. Trauma may also be a factor in eating disorders for some trans people.

The authors conclude that gender dysphoria may be a risk factor for eating disorders in trans women.

By virtue of its emphasis on estrangement from body, transgendered individuals may experience heightened body dissatisfaction and excessive concern with appearance. Accordingly, in certain men, transgenderism may constitute a risk factor for developing an eating disorder. In particular, the presence of a history of otherwise known predisposing risk factors including dieting, a family history of obesity, and significant adverse life events may alert clinicians to more closely screen for an eating disorder among the transgendered population seeking psychiatric consultation.